29 March 2016

Meeting Joe Black

The timeliness of watching Meet Joe Black early in the Easter week experienced here in Chogoria became apparent only late Sunday evening. Joe Black, played by a young frosty-tipped Brad Pitt, is perhaps the most attractive physical embodiment of Death ever created. He comes to get a taste of life the best way possible: alongside wealthy media mogul Bill Parrish (Anthony Hopkins) who is approaching the celebration of his 65th, and apparently last, year. A bit na├»ve to the daily jargon of life, Mr. Black at one point interrupts a board meeting of Parrish’s company when a board member mentions the certainty of death and taxes. “Death and taxes?” he asks, appearing confused and offended.

This week, the inevitability of physical death and the promise of life beyond death were juxtaposed in a way that leaves one pondering most proximately what awaits the deceased after life’s most final event.

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The transition from old class of Medical Officer (MO) Interns to new class of MOIs came rapidly. Highlighted by wrapping up Advanced Cardiac Life Support (ACLS) training and a pot-luck goat roast funded by the hospital Wednesday night complete with speeches from much of the medical staff, the outgoing MOIs were done with their Intern year and headed out to work in various posts around the country. The new MOIs were now on their own, running each of the inpatient services and independently taking care of patients in the outpatient clinic.

The week after their ACLS training, a new MOI and one of our residents led a resuscitative success with a young poorly controlled hypertensive patient. She was shocked once and after some chest compressions and correcting her potassium level, she was alive. Depending on the etiology, resuscitations commonly end with death. And this past week saw a couple of attempts to revive extremely sick patients that ended poorly.


We showed up for rounds Thursday morning to find one of the two MOIs on our service missing. She had gone for a break after spending four of the early morning hours attempting to resuscitate, and eventually losing, two newly admitted patients. One transferred from another hospital down the road, another with severe lower gastrointestinal bleeding. Neither lived to be seen by our staff in the morning. The fellow MOI covered for his teammate. “She is not in a good emotional state, so she went to the house.” I was glad the MOI had made the wise decision to take a break to regroup after a rough morning.

She returned an hour later. No matter how she felt, a busy medical ward needed to be cared for and she was their primary physician. The last couple weeks our ward has had many interesting guests including the rare case of malaria, some brittle diabetics, an older man celebrating his discharge on the same day as his neighbor’s (“The two old men are going home!”), and the police officer who was visited on the ward by his four colleagues wielding a baton, an automatic rifle, and a newspaper.

Towards the end of rounds, the five-member family of our latest death appeared requesting to speak with the MOI. The head sister (nurse) in charge on the ward motioned for me to accompany her and the MOI in the discussion.

What do you say to someone who has had a family member recently pass away? What if you were the one entrusted with keeping them alive?

Many family members here in our area drop off their family members toward the end of life when they sense they cannot provide proper care for their loved one. We then do our best to control their pain and keep them comfortable, managing complications of advancing cancerous masses, bladder obstructions, severe systemic infections, and decreased oral intake. There is no Do-Not-Resuscitate (DNR) order here, so the attempts to revive, and their extent, are decided many times unilaterally by the MOI on call.

The MOI conducted the family meeting in a mixture of Kiswahili and English. She explained in detail the state in which the patient came in, the resuscitation attempt including who was present and what was achieved, and eventually when the elderly gentleman died. The nurse answered practical questions about morgue costs and how they could pay the hospital bill when they eventually took the patient for burial. The patient’s daughter knew death was imminent, she said. “I just didn’t think it would be this morning.” They thanked us and went to view their patriarch one last time.

The MOI admitted afterwards that she had never broken the news of a death to a family. So we debriefed, talking mostly about what she had done well and then what she could improve on for the next time. Remain objective, but show empathy. Discuss details in plain language, but only as much to be complete and adequately informative. Was my approach molded within the American system appropriate for this community? My MOI and I came to a few conclusions. Discussing death is never easy and always different depending on the circumstances and the family.





Then came Easter Sunday. We started with a service here at our campus Presbyterian 9 a.m. English service followed by a group lunch with a few missionary families. It was another beautiful day full of good food and an Easter egg hunt. But the resident was late.


He was called in to assist with the deteriorating patient we had dealt with for a week-and-half. She had just given birth to a healthy baby three weeks prior. Originally diagnosed 10 days ago as septic shock due to her low blood pressures and spiking fevers, a poor condition due to wide-spread infection, and treated with intravenous hydration and several powerful antibiotics, she was not improving. Further investigation with a bedside echocardiogram revealed a heart that was almost not contracting at all and a massive blood clot left by the stagnant blood in her left ventricle. Postpartum, or peripartum, cardiomyopathy was the new diagnosis and we prepared to transfer her to a higher level of care. Our hospital is usually the referral hospital for several smaller facilities nearby, but now we needed help. Before she could be transferred however, she passed away early Sunday afternoon. Her three-week-old infant laid wrapped on the nearby twin bed in the private room with grandmother sitting next to the baby.

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No matter how inevitable, no matter the medical training in objectivity, death hurts. Seeing a death that leaves a healthy three-week-old without her mother begs the obvious question of “Why?”

Following the death of a patient, the discussion many times revolves around justifying both to ourselves and the family that we did “everything we could.” But had we in these cases? Did we have sufficient knowledge, medications, specialists, technology to “do everything?” No way. Had she given birth in my hometown of Austin, her chances of survival would have greatly increased. We could take comfort in knowing we did all that was possible within the constraints of our local system. But considering all the resources available on this planet, we had not truly “done everything.”

Life is precious and perhaps work in medicine offers a close-up yet lopsided view of just how quickly life can change.

Following the grand birthday celebration at the end of the movie and after Parrish has accepted his long, fulfilling life is over, Joe Black and Bill Parrish disappear over the bridge to his death. How peaceful. That romantic depiction of life and its end can occasionally be disrupted. Shaken by a lack of control and confronted with physical death, there must be something beyond that bridge, beyond the mother leaving her infant, that offers hope.

There is so much we can affect in modern medicine, but sometimes death comes. I choose to think Death came as Brad Pitt here in Chogoria. Perhaps I was just too blinded by the circumstances to even see him.


Sunset over Lake Victoria

08 March 2016

"Nice Times"

It was blazing hot. The ice in my drink made the cup sweat. I looked up across the horizon. Blue salt water ahead with the pool in my periphery. This was the life.

Just then, the front my head started to pound. I looked up at the pots of dinner being served on the Maasai-cloth-covered picnic table in our hut. I was wearing all the clothes in my bag and it was only the first night of our three-day climb up Mount Kenya. It was actually near freezing. And this city boy from Texas was ill prepared, clutching the one-liter thick plastic water bottle of recently boiled water. The views were incredible and the company of our six-trekker group assembled by the doctor from New Zealand made the hikes pass quickly. But the cold nighttime weather in a setting slightly outside of my comfort zone had me daydreaming.

I have been guilty of daydreaming before. I’ve even been called out by good friends when they have caught me distracted. So in this first month away, I have been extra careful to consciously ensure I’m present. “In the moment,” some call it. But I am not convinced that is always so easy, or absolutely necessary.


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The excursion to Mt. Kenya was something I had considered prior to coming to Chogoria, so when the group effort had already been coordinated, I decided to take my first trip out of town. We traveled by matatu to Tumutumu to be hosted the night before by a young Pediatrician and her husband from the UK. They fueled us up with chapati and vegetables before the climb. The following morning, we had a proper cappuccino en route to stock up on snacks at the Nakumatt supermarket in Nanyuki before entering the park. It is a beautiful but challenging climb, with the second day requiring an 8-hour, 10-mile, steadily uphill trek. That day left me feeling lousy (perhaps with a bit of the 13,000-foot altitude contributing) at base camp, so I decided against summiting the next morning. Many say Mt. Kenya is tougher than Mt. Kilimanjaro and I now know why.

Following the descent, we were delivered by our guides to a freezing cold shower at Camel Camp, where our final night’s accommodation was in pastoral huts amongst roaming (you guessed it) camels. The following 18 hours replenished the depleted calorie stores and allowed us to soak up the luxuries of the bigger Nanyuki town. Pedicures for the girls, haircut and Irish pub for the boys, a late lunch at Trout Tree, and last but surely not least, the infamous brunch feast at the Mt. Kenya Safari Club. Three thousand shillings ($30), all you can eat buffet including fresh fruit, smoked salmon, multiple cheeses, grilled tomatoes, made-to-order omelettes, sweet breads, cappuccinos, all with a view of the mountain and the colorful hotel grounds. We stocked up with provisions at Nakumatt once more on our way out of town to ensure some comforts made it back to Chogoria.

 








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On the walk home from work the following evening, a man stopped the car on his way out of the hospital’s housing compound. I was with one of the three new physicians from Michigan, in town for a one-month residency rotation. The man stuck his hand out the driver window. “My son – I just dropped him off. He will work at the hospital.” The former camp counselor (and chief resident) came out in me: “Excellent! We’ll take good care of him,” as I shook his hand. The new interns had arrived.

Medical Officers (MO) are those who have just graduated medical school. The MO Interns are those doing their one year of government-assigned rotating training. We have 10 just starting and roughly that many moving on, overlapping for three weeks. The new ones are energetic, ready to learn and serve. The old ones are drained and quick to draw up the call schedule for the new interns, suggesting starting them the day after they arrived in Chogoria. Fortunately, the rookies got a short introduction to the electronic medical record and a tour before being thrown in.

This week we have them out for an Advanced Cardiac Life Support (ACLS) class. This has proven popular with a couple other (higher-ranking, technically) MOs already at the hospital who have sat in on some sessions. Our two residents have been active in teaching the course alongside the Michigan physicians, one of the new young American missionary physicians, and me. Dr. Ritchie, the program director, put in great effort to schedule this course, coordinate the teaching schedule, and block time away for the new interns.

Anyone who has completed or worked in a residency program can tell you: blocking time off for interns can be a surprisingly high hurdle requiring crisis-level diplomacy. If new interns are out, that means old interns, or others, have to work. This ACLS training and the call coverage debate brought back fond memories of residency. These days for the course can be lighter, less stressful, and afford rare time for the intern class to build camaraderie all together. Internship and Residency can be trying on many levels, but the support of your classmates makes it tolerable.

Socially, the interns appear to be settling in well, having perfect attendance at the regular Friday night Pizza Night and a strong presence at the Sunday brunch hosted by the Michigan crew despite some of the interns being on call. There is nothing like free food to attract young physicians, no matter where you live.

Adapting to the role of attending, or “consultant,” has been enjoyable. In morning lectures, residents and interns get called on, while consultants offer advice based on experience. On rounds or in clinic, younger physicians practice medicine and deliver direct care, consultants offer suggestions, guide discussion, and occasionally dive deeper into topics questioned. The expanded opportunities for research and teaching are a welcome shift in daily duties.  

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Living in the moment, enjoying your present, can be a challenge. Slowing down and just being here in Chogoria has taken an unpredictably difficult adjustment from my life in Austin. The daydreaming and living in the future got me here. So, I find it hard to believe that it is all bad as sometimes living in the present requires context. Keeping your vision or your inspiration in focus, I have realized, holds up the backdrop. The present is the main show.

Every time my housekeeper Catherine leaves my place, she thanks me and says goodbye. “Nice times,” she’ll say as she departs. Surely the meaning of that does not perfectly translate, but I cannot stop repeating that aloud to myself. “Nice times.” Nice times, indeed.